Is the Utility of the GLIM Criteria Used to Diagnose Malnutrition Suitable for Bicultural Populations? Findings from Life and Living in Advanced Age Cohort Study in New Zealand (LiLACS NZ).

OBJECTIVES: To investigate associations between nutrition risk (determined by SCREEN-II) and malnutrition (diagnosed by the GLIM criteria) with five-year mortality in Maori and non-Maori of advanced age. DESIGN: A longitudinal cohort study. SETTING: Bay of Plenty and Lakes regions of New Zealand. PARTICIPANTS: 255 Maori; 400 non-Maori octogenarians. MEASUREMENTS: All participants were screened for nutrition risk using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN-II). Those at high nutrition risk (SCREEN-II score <49) had the Global Leadership Initiative in Malnutrition (GLIM) criteria applied to diagnose malnutrition or not. Demographic, physical and health characteristics were obtained by trained research nurses using a standardised questionnaire. Five-year mortality was calculated from Government data. The association of nutrition risk (SCREEN-II) and a malnutrition diagnosis (GLIM) with five-year mortality was examined using logistic regression and cox proportional hazard models of increasing complexity. RESULTS: 56% of Maori and 46% of non-Maori participants had low SCREEN-II scores indicative of nutrition risk. The prevalence of GLIM diagnosed malnutrition was lower for both Maori and non-Maori (15% and 19% of all participants). Approximately one-third of participants (37% Maori and 32% non-Maori) died within the five-year follow-up period. The odds of death for both Maori and non-Maori was significantly lower with greater SCREEN II scores (better nutrition status), (OR (95% CI); 0.58 (0.38, 0.88), P < 0.05 and 0.53 (0.38, 0.75), P < 0.001, respectively). GLIM diagnosed malnutrition was not significantly associated with five-year mortality for Maori (OR (95% CI); 0.88 (0.41, 1.91), P >0.05) but was for non-Maori. This association remained significant after adjustment for other predictors of death (OR (95% CI); 0.50 (0.29, 0.86), P< 0.05). Reduced food intake was the only GLIM criterion predictive of five-year mortality for Maori (HR (95% CI); 10.77 (4.76, 24.38), P <0.001). For non-Maori, both aetiologic and phenotypic GLIM criteria were associated with five-year mortality. CONCLUSION: Nutrition risk, but not malnutrition diagnosed by the GLIM criteria was significantly associated with mortality for Maori. Conversely, both nutrition risk and malnutrition were significantly associated with mortality for non-Maori. Appropriate phenotypic criteria for diverse populations are needed within the GLIM framework.

Assessment of Dietary Intake in Three Cohorts of Advanced Age in Two Countries: Methodology Challenges.

OBJECTIVES: Dietary intake information is key to understanding nutrition-related outcomes. Intake changes with age and some older people are at increased risk of malnutrition. Application, difficulties, and advantages of the 24-hour multiple pass recall (24hr-MPR) dietary assessment method in three cohorts of advanced age in the United Kingdom (UK) and New Zealand (NZ) is described. PARTICIPANTS: The Newcastle 85+ study (UK) recruited a single year birth cohort of people aged 85 years during 2006-7. LiLACS NZ recruited a 10-year birth cohort of Maori (indigenous New Zealanders) aged 80-90 years and a single year birth cohort of non-Maori aged 85 years in 2010. MEASUREMENTS: Two 24hr-MPR were conducted on non-consecutive days by trained assessors. Pictorial resources and language were adapted for the New Zealand and Maori contexts. Detailed methods are described. RESULTS: In the Newcastle 85+ study, 805 (93%) participants consented to the 24-MPR, 95% of whom completed two 24hr-MPR; in LiLACS NZ, 218 (82%) consented and 203 (76%) Maori and 353 (90%) non-Maori completed two 24hr-MPR. Mean time to complete each 24hr-MPR was 22 minutes in the Newcastle 85+ study, and 45 minutes for Maori and 39 minutes for non-Maori in LiLACS NZ. Dietary assessment of participants residing in residential care and those requiring proxy respondents were successfully included in both studies. Most participants (83-94%) felt that data captured by the 24hr-MPR reflected their usual dietary intake. CONCLUSIONS: Dietary assessment using 24hr-MPR was successful in capturing detailed dietary data including information on portion size and time of eating for over 1300 octogenarians in the UK and New Zealand (Maori and non- Maori). The 24hr-MPR is an acceptable method of dietary assessment in this age group.

Medication taking in a national sample of dependent older people.

BACKGROUND: Polypharmacy is associated with inappropriate medication use, and subsequently increasing older persons' risk of drug-related harm and health-related costs to individuals and society. OBJECTIVE: To examine and describe, using a national sample of patient-level medication data, the prevalence of older people's polypharmacy and medication use across dependency levels. To examine oral and general pain prevalence and associated analgesic usage. METHODS: Medication data from the 2012 New Zealand Older People's Oral Health Survey, a nationally-representative, cross-sectional study of dependent older people's oral health, were analysed descriptively, comparing classes and sub-classes of drugs and nutrient supplements taken across four categories of dependency: very low (own homes receiving in-home support), low, high and psychogeriatric (all receiving aged residential care). Self-reported current general pain and frequency of orofacial pain data were cross-tabulated by sub-classes of analgesics taken. RESULTS: All participants were taking at least one medication overall, 53.2% (95% CI: 50.4, 56.0) took between five and nine (polypharmacy), and 13.9% (95% CI: 17.4, 22.5) took 10 or more (hyperpolypharmacy). Antihypertensives, analgesics, antiulcer drugs, aspirin, laxatives, statins and antidepressants were the most common drug classes taken, the proportions differing between psychogeriatric level care and all other dependency groups. Overall, simple analgesics were taken (34.5%; 95%CI: 30.8, 38.4) more commonly than other analgesics; the use of nonsteroidal anti-inflammatory drugs was low (3.6%; 95% CI: 2.7, 4.7). Of those reporting experiencing extreme general bodily pain, 63.3% (95% CI: 56.6, 69.4) took an analgesic, more than those experiencing mouth pain occasionally or often. Fat-soluble vitamins were the most common vitamin supplement taken (32.0%; 95%CI: 27.0, 37.4). CONCLUSIONS: Polypharmacy and hyperpolypharmacy are common among older people, regardless of dependency level, and pain may be undertreated.

Reducing emergency presentations from long-term care: A before-and-after study of a multidisciplinary team intervention.

INTRODUCTION: The complexity of care required by many older people living in long-term care (LTC) facilities poses challenges that can lead to potentially avoidable referrals to a hospital emergency department (ED). The Aged Residential Care Intervention Project (ARCHIP) ran an implementation study to evaluate a multidisciplinary team (MDT) intervention supporting LTC facility staff to decrease potentially avoidable ED presentations by residents. METHODS: ARCHIP (conducted in 21 facilities [1,296 beds] with previously noted high ED referral rates) comprised clinical coaching for LTC facility staff by a gerontology nurse specialist (GNS) and an MDT (facility senior nurse, resident's general practitioner, GNS, geriatrician, pharmacist) review of selected high-risk residents' care-plans. A before-after repeated measures analysis was conducted for 9 months before and 9 months after intervention commencement (a 29-month period because of staggered facility enrolment). Modelling was adjusted for time trend, seasonality, facility size, and cluster effect. RESULTS: ED admission rate ratio post- versus pre-intervention was 0.75 (95% C.I. 0.63, 0.89, p-value = 0.0008), a 25% reduction in ED presentations post-intervention. A sensitivity model used a shorter, staggered time period centred on intervention start (9 months pre-intervention and 9 months post-intervention) for each facility, and a four-level categorical intervention variable testing intervention effect over time. The sensitivity test showed a 24% reduction in ED presentations in months 1-3 post-intervention (p-value = 0.07), a 34% reduction in months 4-6 (p-value = 0.01), and a 32% reduction in ED presentations in months 7-9 (p-value = 0.03). However, when the higher ED referral rates for 3 months immediately pre-intervention were modelled, the impact of the intervention on ED presentation rates reverted almost to previous levels. KEY CONCLUSIONS: A GNS-led MDT outreach intervention, targeted at selected conditions, decreases avoidable ED admissions of high-risk residents from selected facilities.

Health and Social Factors Associated with Nutrition Risk: Results from Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ).

OBJECTIVES: To establish the prevalence of high nutrition risk and associated health and social risk factors for New Zealand Maori and non-Maori in advanced age. DESIGN: A cross sectional analysis of inception cohorts to LiLACS NZ. SETTING: Bay of Plenty and Lakes region of the North Island, New Zealand. PARTICIPANTS: 255 Maori and 400 non- Maori octogenarians. MEASUREMENTS: Nutrition risk was assessed using a validated questionnaire Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II). Demographic, social, physical and health characteristics were established using an interviewer administered questionnaire. Health related quality of life (HRQOL) was assessed with the SF-12, depressive symptoms using the GDS-15. RESULTS: Half (49%) of Maori and 38% of non-Maori participants were at high nutrition risk (SCREEN II score <49). Independent risk factors were for Maori younger age (p=0.04), lower education (p=0.03), living alone (p<0.001), depressive symptoms (p=0.01). For non- Maori high nutrition risk was associated with female gender (p=0.005), living alone (p=0.002), a lower physical health related quality of life (p=0.02) and depressive symptoms (p=0.002). CONCLUSION: Traditional risk factors apply to both Maori and non-Maori whilst education as indicative of low socioeconomic status is an additional risk factor for Maori. High nutrition risk impacts health related quality of life for non-Maori. Interventions which socially facilitate eating are especially important for women and for Maori to maintain cultural practices and could be initiated by routine screening.

The BRIGHT Trial: what are the factors associated with nutrition risk?

OBJECTIVES: To determine the nutrition risk status and factors associated with nutrition risk among older adults enrolled in the Brief Risk Identification Geriatric Health Tool (BRIGHT Trial). DESIGN: A cluster randomised controlled trial. SETTING: Three main centres in New Zealand. PARTICIPANTS: A total of 3,893 older adults were recruited from 60 general practices in three of the District Health Board (DHB) regions aged 75 years and older (or 65 years and older if Maori). MEASUREMENTS: Nutrition risk was assessed using the Australian Nutrition Screening Initiative (ANSI). Validated questionnaires were used to establish quality of life (WHOQOL-BREF), physical function (the Nottingham Extended Activities of Daily Living) and depressive symptoms (15 item Geriatric Depression Scale). Demographic, standard of living and health data were established. RESULTS: Sixty two percent of participants were identified to be at moderate or high nutrition risk. The mean ANSI score was 4.9 (range 0-21, maximum 29). Factors which independently predicted moderate or high nutrition risk were female gender, being Maori and other ethnicities versus European, not being married, taking multiple medications, having more depressive symptoms, cardiovascular disease and diabetes. Protective factors independently related to low nutrition risk were living with others, higher physical and social health related QOL and higher functional status. WHOQOL environmental and psychological factors were not associated with nutrition risk when other predictive factors were taken into account. CONCLUSION: Nearly two thirds of participants were identified to be at higher nutrition risk. Women, living alone, taking multiple medications, with depressive symptoms, cardiovascular disease and ndiabetes were factors associated with higher nutrition risk. Those at low nutrition risk had a better functional status and physical and social health related QOL.

Validation of the nutrition screening tool 'Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II' among octogenarians.

OBJECTIVE: To determine the validity of the nutrition screening tool 'Seniors in the Community: Risk Evaluation for Eating and Nutrition, version II' (SCREEN II) among a purposive sample of octogenarians. DESIGN: Cross-sectional validation study. SETTING: Bay of Plenty, New Zealand. PARTICIPANTS: Forty-five community-living residents aged 85-86 years. Equal proportions of participants were recruited at low, medium and high nutrition risk based on their SCREEN II score 12 months prior. MEASUREMENTS: Nutrition risk was assessed using SCREEN II. Demographic and health data were established. Using established criterion a dietitian's nutrition risk rating assessment ranked participants from low risk (score of 1) to high risk (score of 10). The assessment included a medical history, anthropometric measures and dietary intake. Dietary intake was established from three 24 hour multiple pass recalls (MPR). A Spearman's correlation determined the association between the SCREEN II score and the dietitian's risk score. Receiver operating characteristic (ROC) curves were completed to determine the sensitivity and specificity of the cut-off point for high nutrition risk. RESULTS: The SCREEN II score was significantly correlated with the dietitian's risk rating (rs = -0.76 (p<0.01). A newly defined cut-off point <49 was established for high nutrition risk derived from ROC curves and AUC (0.87, p < 0.01); sensitivity 90% and specificity 86%. CONCLUSION: SCREEN II is a simple, easy to use, 14 item questionnaire and appears to be a valid tool for detection of nutrition risk people aged 85-86 years.

Development of a standard fall data format for signals from body-worn sensors : the FARSEEING consensus.

Objective measurement of real-world fall events by using body-worn sensor devices can improve the understanding of falls in older people and enable new technology to prevent, predict, and automatically recognize falls. However, these events are rare and hence challenging to capture. The FARSEEING (FAll Repository for the design of Smart and sElf-adapaive Environments prolonging INdependent livinG) consortium and associated partners strongly argue that a sufficient dataset of real-world falls can only be acquired through a collaboration of many research groups. Therefore, the major aim of the FARSEEING project is to build a meta-database of real-world falls. To establish this meta-database, standardization of data is necessary to make it possible to combine different sources for analysis and to guarantee data quality. A consensus process was started in January 2012 to propose a standard fall data format, involving 40 experts from different countries and different disciplines working in the field of fall recording and fall prevention. During a web-based Delphi process, possible variables to describe participants, falls, and fall signals were collected and rated by the experts. The summarized results were presented and finally discussed during a workshop at the 20th Conference of the International Society of Posture and Gait Research 2012, in Trondheim, Norway. The consensus includes recommendations for a fall definition, fall reporting (including fall reporting frequency, and fall reporting variables), a minimum clinical dataset, a sensor configuration, and variables to describe the signal characteristics.

Proposal for a multiphase fall model based on real-world fall recordings with body-fixed sensors.

Falls are by far the leading cause of fractures and accidents in the home environment. The current Cochrane reviews and other systematic reviews report on more than 200 intervention studies about fall prevention. A recent meta-analysis has summarized the most important risk factors of accidental falls. However, falls and fall-related injuries remain a major challenge. One novel approach to recognize, analyze, and work better toward preventing falls could be the differentiation of the fall event into separate phases. This might aid in reconsidering ways to design preventive efforts and diagnostic approaches. From a conceptual point of view, falls can be separated into a pre-fall phase, a falling phase, an impact phase, a resting phase, and a recovery phase. Patient and external observers are often unable to give detailed comments concerning these phases. With new technological developments, it is now at least partly possible to examine the phases of falls separately and to generate new hypotheses.The article describes the practicality and the limitations of this approach using body-fixed sensor technology. The features of the different phases are outlined with selected real-world fall signals.

Orientation to dissection: Assisting students through the transition.

Human dissection continues to be strongly argued for teaching human anatomy to medical students and is technically and emotionally demanding. An orientation to dissection and the laboratory are provided for students before beginning their work because students' and families' reactions to dissection are often complex. This study explored medical students' experiences of attending an orientation to human dissection and the anatomy laboratory. Students' reactions, feelings, and thoughts were enquired about 1 year after beginning dissection at the University of Auckland, New Zealand. Qualitative research methods, specifically one-on-one semistructured interview were utilized. Third-year medical students self-selected into the study and were interviewed 1 year after entering the laboratory. Transcribed audiotapes of the interviews were analyzed for themes across the interviews. One year after dissection students have vivid memories with differing ways of viewing the body that may help or hinder with dissection. The themes presented include orientation, student anticipation, psychological approach to the body, normalizing-continuing disquiet, and social reference. The orientation eases student entry into the laboratory. There can be ongoing feelings of ambivalence regards the body for some students. Novel findings include that students not only have their own feelings to deal with but also those of friends and family who question them and may feel uncomfortable with the idea of them dissecting. Even one year after beginning dissection, students may emotionally struggle with their work and may require further support, including how they talk about sensitive topics with other people.

What is associated with nutrition risk in very old age?

OBJECTIVES: To identify factors associated with nutrition risk among a purposive sample of those in advanced aged. DESIGN: A cross sectional feasibility study. SETTING: Three North Island locations in New Zealand. PARTICIPANTS: One hundred and eight community-living residents aged 75- 85 years. MEASUREMENTS: Nutrition risk was assessed using a validated questionnaire, Seniors in the Community: Risk Evaluation for Eating and Nutrition, Version II (SCREEN II). A Physical Activity Scale for the Elderly (PASE) was used to determine level of physical activity. Markers of body composition, grip strength and fasting blood samples were collected. RESULTS: Fifty-two percent of participants were at high nutrition risk (SCREEN II score < 50; range 29-58; out of maximum score 64). The mean score for SCREEN II was higher for older people who lived with others (50.3 ± 5.1) compared to those who lived alone (46.4 ± 5.8) p=0.001. The SCREEN II score was positively correlated with the total PASE score r= 0.20 (p=0.042), grip strength r=0.20 (p=0.041), and muscle mass percentage r=0.31 (p=0.004). Lower levels of haemoglobin, serum zinc and physical activity were associated with higher nutrition risk. CONCLUSION: Half the participants were at high nutrition risk. They tended to be widowed or live alone and had lower levels of haemoglobin and serum zinc. Those at lower nutrition risk had greater muscle mass and strength, lower body fat, consumed alcohol more frequently and engaged in more physical activity. Strategies which encourage older people to eat meals and be physically active with others may assist to improve their health.

How is the risk of undernutrition associated with cardiovascular disease among individuals of advanced age?

BACKGROUND: The oldest old (85+) are the fastest growing population segment in New Zealand. Cardiovascular disease (CVD) is the main cause of death and is associated with various risk factors including risk of undernutrition. OBJECTIVES: To determine if there is an association between CVD and nutrition risk in advanced age. SETTING: Three North Island locations (rural and urban areas) in New Zealand. PARTICIPANTS: 108 participants aged 85 years (75-79 for Maori). MEASUREMENTS: Comprehensive health assessments were undertaken. Clinically manifest CVD was pre-defined and ascertained from interviews and hospitalisation records. Nutrition risk was assessed using a validated questionnaire-Seniors in the Community: Risk evaluation for eating and nutrition, Version II (SCREEN II). RESULTS: 72 participants (67%) had CVD (49% men); 52% of participants had a SCREEN II score < 50. Those with CVD had lower HDL level [median(IQR)] [1.4(0.7) vs. 1.6(0.6)] (p=0.041), and higher waist circumference [97.5(19.1) vs. 89.3(20.6)] (p=0.043) compared to those without CVD. Those with CVD were at no greater nutrition risk than those without CVD (SCREEN II score: [49(7) vs. 51(10)] (p=0.365). Using logistic regression controlling for confounders, SCREEN II scores trended towards an inverse association with CVD (p=0.10). CONCLUSION: Two thirds of the study participants had CVD and half were at risk of undernutrition. Nutrition risk was mildly associated with CVD. This study provides further evidence that those in advanced age are at risk of undernutrition. Further research is needed to establish how the causes and consequences of CVD are related to nutrition risk.

The prepare pilot RCT of home-based progressive resistance exercises for venous leg ulcers.

OBJECTIVE: To establish the feasibility of conducting a home-based progressive resistance exercise programme to improve calf muscle pump function in community-based patients with venous leg ulcers. METHOD: Participants were randomised to receive a 12-week progressive resistance exercise programme using heel raises in addition to compression. The control was usual care in addition to compression. Randomisation was stratified by ulcer duration and ulcer size. Air plethysmography was used to determine changes in calf muscle pump function from baseline. Changes in ulcer parameters were measured using the SilhouetteMobile device. RESULTS: Forty participants were randomised. There were significantly greater improvements in ejection fraction of the calf muscle in the exercise group compared with the control (usual care) group (mean difference 18.5%, 95% CI 0.03 to 36.6%, p<0.05). Other parameters improved in the exercise group but the mean differences were not significant. Adherence with prescribed exercises was 81% and there was no significant difference in the numbers reporting adverse events. There were also no significant differences in ulcer healing parameters (change in area, percentage change in area, number healed at 12 weeks, time to healing). CONCLUSION: A community-based randomised trial of progressive resistance exercise is feasible. The prescribed exercises appeared to increase ejection fraction, but the effect of exercise on ulcer healing requires further investigation.

An association between ethnicity and cardiovascular outcomes for people with Type 2 diabetes in New Zealand.

AIMS: To investigate the association between ethnicity and risk of first cardiovascular (CV) event for people with Type 2 diabetes in New Zealand. METHODS: A prospective cohort study using routinely collected data from a national primary health care diabetes annual review programme linked to national hospital admission and mortality data. Ethnicity was recorded as European, Maori, Pacific, Indo-Asian, East-Asian or Other. A Cox proportional hazards model was used to investigate factors associated with first CV event. Data was collected from 48,444 patients with Type 2 diabetes, with first data collected between 1 January 2000 and 20 December 2005, no previous cardiovascular event at entry and with complete measurements. Risk factors included ethnicity, gender, socio-economic status, body mass index, smoking, age at diagnosis, duration of diabetes, systolic blood pressure, serum lipids, glycated haemoglobin and urine albumin : creatinine ratio. The main outcome measures were time to first fatal or non-fatal CV event. RESULTS: Median follow-up was 2.4 years. Using combined European and Other ethnicities as a reference, hazard ratios for first CV event were 1.30 for Maori (95% confidence interval 1.19-1.41), 1.04 for Pacific (0.95-1.13), 1.06 for Indo-Asian (0.91-1.24) and 0.73 for East-Asian (0.62-0.85) after controlling for all other risk factors. CONCLUSIONS: Ethnicity was independently associated with time to first CV event in people with Type 2 diabetes. Maori were at 30% higher risk of first CV event and East-Asian 27% lower risk compared with European/Other, with no significant difference in risk for Pacific and Indo-Asian peoples.

Reducing hazard related falls in people 75 years and older with significant visual impairment: how did a successful program work?

BACKGROUND: In a randomized controlled trial testing a home safety program designed to prevent falls in older people with severe visual impairment, it was shown that the program, delivered by an experienced occupational therapist, significantly reduced the numbers of falls both at home and away from home. OBJECTIVES: To investigate whether the success of the home safety assessment and modification intervention in reducing falls resulted directly from modification of home hazards or from behavioral modifications, or both. METHODS: Participants were 391 community living women and men aged 75 years and older with visual acuity 6/24 meters or worse; 92% (361 of 391) completed one year of follow up. Main outcome measures were type and number of hazards and risky behavior identified in the home and garden of those receiving the home safety program, compliance with home safety recommendations reported at six months, location of all falls for all study participants during the trial, and environmental hazards associated with each fall. RESULTS: The numbers of falls at home related to an environmental hazard and those with no hazard involved were both reduced by the home safety program (n = 100 participants) compared with the group receiving social visits (n = 96) (incidence rate ratios = 0.40 (95% confidence interval, 0.21 to 0.74) and 0.43 (0.21 to 0.90), respectively). CONCLUSIONS: The overall reduction in falls by the home safety program must result from some mechanism in addition to the removal or modification of hazards or provision of new equipment.

Effect of the addition of a "help" question to two screening questions on specificity for diagnosis of depression in general practice: diagnostic validity study.

OBJECTIVE: To determine the validity of two written screening questions for depression with the addition of a question inquiring if help is needed. DESIGN: Cross sectional validation study. SETTING: 19 general practitioners in six clinics in New Zealand. PARTICIPANTS: 1025 consecutive patients receiving no psychotropic drugs. MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios of the two screening questions, the help question, combinations of the screening and help questions, and diagnosis by general practitioners. RESULTS: The help question alone had a sensitivity of 75% (95% confidence interval 60% to 85%) and a specificity of 94% (93% to 96%). The positive likelihood ratio for the help question was 13.0 (9.5 to 17.8) and the negative likelihood ratio was 0.27 (0.17 to 0.44). The likelihood ratio for patients wanting help today was 17.5 (11.8 to 31.9). The general practitioner diagnosis had a sensitivity of 79% (65% to 88%) and a specificity of 94% (92% to 95%). CONCLUSION: Adding a question inquiring if help is needed to the two screening questions for depression improves the specificity of a general practitioner diagnosis of depression.

Falls: a comparison of trends in community, hospital and mortality data in older Australians.

BACKGROUND AND AIMS: Falls are major contributors to disability, morbidity and death for older people. Frequently, falls-related data for each of these areas is viewed in isolation. The aim of this study was to establish trends in incidence of falls-related events including: community reporting of falls and falls-related injuries, hospitalizations as a result of accidental falls, and mortality related to accidental falls for older people in two states of Australia (Victoria and South Australia). METHODS: We analysed data sets for falls hospitalizations and mortality rates for the period 1988 to 1997, and from two longitudinal population-based proportional samples during the same time period. RESULTS: Age-standardised falls mortality rates have steadily declined in Victoria, and remained unchanged between 1988 and 1997 in South Australia. In both states, age-standardised falls hospitalization rates have increased significantly (in Victoria, RR=1.32, 95% CI: 1.30-1.34; and South Australia, RR=1.05, 95% CI: 1.03-1.06). In both states, there was a clear age-related effect, with those in the 85-year and older age group having a falls-related mortality rate approximately 40 times that of those aged 65-69 years, and a hospitalization rate 9 times that of those in the 65-69 age group. The community studies indicated that falls rates remain high among older Australians, and that injurious falls occurred in 10% in the first wave of data collection in each of these studies. CONCLUSIONS: The results highlight that various indicators related to falls trends taken in isolation may yield differing conclusions. For a true reflection of the effectiveness of falls prevention programs, falls-related mortality, hospitalization and community data need to be integrated. Increased focus on falls prevention activity in Australia during the 1990's has not reduced the magnitude of this major public health problem.

Do delayed prescriptions reduce the use of antibiotics for the common cold? A single-blind controlled trial.

OBJECTIVE: To test the use of a delayed prescription compared with instructions to take antibiotics immediately in patients presenting to family physicians with upper respiratory tract infections (common colds). STUDY DESIGN: Randomized controlled single-blind study. POPULATION: Subjects were 129 patients presenting with the common cold who requested antibiotics or whose physicians thought they wanted them. All patients were in a family practice in Auckland, New Zealand, consisting of 15 physicians (9 male, 6 female) who had completed medical school between 1973 and 1992. OUTCOMES MEASURED: Outcomes were antibiotic use (taking at least 1 dose of the antibiotic), symptom scores, and responses to the satisfaction questions asked at the end of the study. RESULTS: Patients in the delayed-prescription group were less likely to use antibiotics (48%, 95% CI, 35%-60%) than were those instructed to take antibiotics immediately (89%, 95% CI, 76%-94%). Daily body temperature was higher in the immediate-prescription group. The lack of difference in the symptom score between the 2 groups suggests that there is no danger in delaying antibiotic prescriptions for the common cold. CONCLUSIONS: Delayed prescriptions are a safe and effective means of reducing antibiotic consumption in patients with the common cold. Clarification of patient expectations for antibiotics may result in a lower prescription rate. When the patient demands a prescription, delaying its delivery has the potential to provide gentle education.

Evidence databases, the Internet, and general practitioners: the New Zealand story.

AIM: To determine self-reported access to and use of the Internet and the Cochrane Library by general practitioners (GPs) in New Zealand. METHODS: A national cross sectional postal and fax survey of randomly selected GPs. RESULTS: A total of 381 of 459 eligible GPs returned completed questionnaires (83%). The mean age of this sample was 45.7 years (SD 8.6) and average years in general practice was 15.7 years (SD 8.8 years). 74% (277) were male and 77% (289) in full-time practice. Internet access was present in 40% (95% CI 36-46%) of practices and 76% (72-81%) of GP's homes. The majority, 56% (51-61%), of GPs had used the Internet with regard to a patient. Younger GPs (<35 years old OR = 2.69, 95% CI 1.10-6.60) and male GPs (OR 1.72, 95% CI 1.02-2.90) were significantly more likely to report use of the Internet with respect to patients. 42% (95% CI 37-47%) of GPs were aware of the Cochrane Library but only 15% (11-19%) had used it. Those in group practice were more likely to be aware of the Cochrane database (adjusted OR 1.85, CI 1.09-3.12). CONCLUSIONS: Internet use is prevalent among GPs. Solo practitioners, older GPs and female GPs are least likely to avail themselves of this resource. Although half of GPs knew about Cochrane, a minority used it. Access and use of evidence databases can be improved in New Zealand. Strategies to assist those least likely already to use Cochrane may help our collective efforts towards evidence based practice.